HomeMy WebLinkAbout0011 KEEL WAY - Health Feel Way
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• COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 11 Keel Way
Hyannis, MA 02601
Owner's Name: Barbara FunQaroli 3o�8
Owner's Address: 25 Landv Avenue TY
Florence,MA 01062
Date of Inspection: July 16, 2005 F
Name of Inspector: (Please Print) James M. Ford
• C_j
Company Name: James M. Ford
C. r
Mailing Address: P.O.Box 49 -�
Osterville,MA 02655-0049 v` v, '
Telephone Number: (508) 862-9400 0
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CERTIFICATION STATEMENT �� y
I certify that I have personally inspected the sewage disposal system at this address and that the i ormation-reported
below is true, accurate and complete as of the time of the inspection. The inspection was perfomied based``On my"'
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Need Further Evaluation by the Local Approving Authority
✓ Fail
Inspector's Signature: Date: July 20. 2005
The system.inspector shall sub i a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
,' F .Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
• ` r time.This inspection does not address how the system will perform in the future under the same or different
conditions of use..
Title 5 lnspection Form- 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 Keel Way
Hyannis, MA
Owner: Barbara Fungaroli
Date of Inspection: July 16, 2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments-
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND.explain:
2
Page 3 of 1 I
OFFICIAL INSPECTION FORM-" NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 Keel Way
_ Hyannis. MA
Owner: Barbara FunQaroli
Date of Inspection: July 16. 2005
i
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
• r •
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
i
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Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 Keel Wav .
_ Hyannis, MA
Owner: Barbara Funzaroli
Date of Inspection: July 16, 2005
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No -,
✓ Backup of sewage into facility or system.component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool ,
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
NOTE:SINGLE CESSPOOLS AUTOMATICALLY FAIL IN THE TOWN OF BAItNSTABLE.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd•
You must indicate either"yes"or"no"to each of the following
(The following criteria apply to large systems in addition to the criteria above)
.Yes No
the system is within 400 feet of a surface drinking water supply
t , the system is within 200 feet of a tributary to a surface drinking water supply r
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
•= If you have answered"yes"y yes to any question in Section E the system is considered a significant threat, or answered `
+` "yes" in Section D above the large system has failed. The owner or operator of any large system considered a "
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
415.3041' The system owner should contact the appropriate regional office of the Department. . h
• Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 11 Keel Way
Hyannis, MA
Owner: Barbara FunQaroli
Date of Inspection: July 16, 2005 "
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,'occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in'the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as NIA)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ Was the facility owner(and occupants if different from owner)provided with information on the,proper ,
maintenance of subsurface sewage disposal systems? "
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance .
is unacceptable) [310 CMR 15.302(3)(b)]: _
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k' Y 5 ,
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 11 Keel Way
_ Hyannis. MA
Owner: Barbara Funoaroli
Date of Inspection: July 16, 2015
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): n/a Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): n/a
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of infonnation: Pumped 5 years ago-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank, distribution box,soil absorption system
✓ Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative.technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Date.ofinstallation unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
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Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Keel Way
Hyannis, MA
Owner: _ Barbara FunQaroli
Date of Inspection: July 16, 2005
BUILDING SEWER(locate on site plan)
Depth below grade: None
Materials of construction: _cast.iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage,etc.):
SEPTIC TANK: None (locate on site plan)
Depth below grade: _
Material of construction: _concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
' Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:'
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
:.i as related to outlet invert, evidence of leakage,etc.):
8 Y.
.> 7
Page 8 of 11
OFFICIAL INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE iDISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 11 Keel Way
Hvannis, MA
Owner: Barbara Fungaroli
Date of Inspection: July 16, 2005
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: eallons
Design Flow: allons/day r
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etch: ,
I -
DISTRIBUTION BOX: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: ,
Cormnents(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Y:
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Y {• •� 8
Page 9 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: II Keel Way
_ Hyannis. MA
Owner: Barbara Funzaroli
Date of Inspection: July 16, 2005
SOIL ABSORPTION SYSTEM(SAS): None (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number: .
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments (note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 1 single cesspool
Depth-top of liquid to inlet invert: --
Depth of solids layer: 10"
Depth of scum layer: 2"
Dimensions of cesspool: 5'W x 7'T x 9'bottom to grade
Materials of construction: Cesspool block
Indication of groundwater inflow(yes or no): No
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
The cesspool had]'of IL
quid on the bottom The bottom to grade was 9' The cover was 2 5'below grade NOTE Single
cesspools automatically fail in the Town of Barnstable
PRIVY: None (locate on site plan)
i Materials of construction:
Dimensions:
Depth of solids:
Conunents(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
I
s
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' - PART C
SYSTEM INFORMATION(continued)
Property Address: _11 Keel Way
Hvannir MA
Owner: Barbara Fun aroli
Date of Inspection: July 16, 2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page 11 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: II Keel Way
Hyannis, MA
Owner: Barbara Fungaroli
Date of Inspection: July 16, 2005
I
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
i
Estimated depth to ground water 25 +/- feet
Please indicate(check)all methods used to determine the high ground water elevation: t
Obtained from system design plans on record=If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours snaps
Checked with local excavators, installers-(attach documentation)
• Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours traps the maps were showing gpproximately 25'+1-to ground water at this
site.
• i
't
F�. • This report has been prepared and the systent inspected and failed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. ,
TOWN OF BARNSTABLE
L;:;CATION SEWAGE # —�
"� IIL GAGA E l� SSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (ty ) . C. d1 ,G• (size) e_�_7 7?r 1l//KI/
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: 7) t,�-G COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching FacilityFeet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) _ Feet
Edge of Wetland and Leaching Facility(If any wetlands exist r
within 300 feet of leaching facility) '' Feet'
Furnished by
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TOWN OF-EARNSTABLE
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LOCATION �I SEWAGE # -
'*�,LLAGE N�/gM�-s ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY G2S1p00
LEACHING FACILITY: (type)'
NO. OF BEDROOMS
BUILDER OR OWNER �ra'
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PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching1facility) / Feet
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No. 00 — _ Fee 100 -
HE &MMONWEALTH OF MA$SACHUSETTS Entered in computer: f/
Yes
PUBLIC HEALYH DISISION -TOWN OF BARNSTABLE.,MASSACHUSETTS
01ppYication for -Mi!5p0$al bpgtem COttgtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade(b4 Abandon( ) Xkomplete System ❑Individual Components
Location Address or Lot No. Kr-,_-L w.qy Owner's Name,Address and Tel.No.
Assessor's Map/Parcel ;; %-O— I 1 " Y u` 0�
Installer's N e,Address,and Tel.No. Designer's Name`,Address and Tel.No.
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Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow -7:3 3 0 gallons per day. Calculated daily flow 3 31 gallons.
Plan Date `-�- �,C�—0 Number of sheets Revision Date
Title NJ C-
Size of Se tic Tank 00 VO4 0%,_ AT�y�p�e off1S.A.S. �� . # U 37.?S)r
Description of Soil y �y S aA� , 111 ye c sXA,,/� r
Nature of Repairs or Alterations(Answer when applicable) Oey. l A-tJL
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this Board of ealth.
Signed Date "7-��'6s
Application Approved by Date
Application Disapproved for the f owing reasons
Permit No. av,>S--3 L Date Issued 7—0—U1r
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/00
4V'' No. 00 � � Fee
Hl=2tw.'OMMONWEALTH OF II `ASHUSETTS Entered in computer.
PUBLIC HEALi H " V/ISION - TOWN OF BAR NSTABLEi" S ACHUSETTS Yes
01ppYication for biz*opal *pgtem 3Conotruct on Permit
Application for a Permit to Construct(�" )Repair( )Upgrade Abandon( ) Complete System O Individual Components
Location Address or Lot No. / L 6✓A7 ecaT owner's Name,Address and Tel.No.
Assessor's Map/Parcel9l oG� ;.
Installer's Name,Address,and Tel.No. lG Designer's Name,Address and Tel.No. ti
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Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( ) i
Other Fixtures i
' Design Flow gallons per day. Calculated daily flow 3_3 gallons. �.
Plan Date _!:7 _G -n\ Number of sheets Revision Date �-
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{ Title 1 ,c U s J ,
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Size of S tic Tank DO �i V1 -A�o�- Type of S.A.S. .C Xr r L✓ l u J-7.2s )r '
Description of Soil�. -- l V41yv`y
Nature of Repairs or Alterations(Answer when applicable) f- _? ANS
Date last inspected:
Agreement: -p
- The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate
Cate of Compliance has been issued by this Board o Health. ti
Signe Date -7—,90j ti
Application Approved by Id, Q IR-S Date '�7--t 9—(--
Application Disapproved for the ATowing reasons r Y
Permit No. a y0�`- 2 L/ I Date Issued 7- l 9-G r
�. . ------------------------------------=
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance 3,&d1WAs.
t THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded(k--1 )
Abandoned ( )by n._ c
at l Ju l o, P-L-A O has been constructed in accordance
with the pro s`of Title 5 and the for Disposal Sys em Construction Permit No. 200 S 3 L�/ dated 7-/GJ-D S'-
InstallVA iP 1�p:k-s Desig
The issuance of this permit shall not be construed as a guarantee that he syste, i 1 un iogas designed.
Date Inspector e
No. fl.U Fee Jo
O
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS
1=igpo!6a1 *pgtem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade(a.�bandon( )
System located at I
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Constructio2 must be completed within three years of the date of th' pe it.n
Date:_.- ( � Approved by
��
9/16/03
Notice: This Form Is To Be Used For the Repair Of Vailed
Septic Systems. Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, hereby certify that the engineered plan signed by me
dated concerning the property located at
' 11
u, meets. all of the
following criteria:
• This failed system is connected to'a residential dwelling only. There.are.no.commercial or
business uses associated with the.-dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or.may conduct deep
test holes and percolation tests.at the site without a health agent present.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The.bottom of the proposed leaching facility will be.located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) 4-a.d0
B) G.W.Elevation S +adjustment for high G.W. %I, _ O
DIFFERENCE BETWEEN A and B 3 •.�O
SIGNFD : DATE: IRI oig
NOTICE
Based upon the above information;a repair permit will be issued for bedrooms
maximum.. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASeptic\pemexemp.doc
Town of Barnstable
�p1HE T Regulatory Services
Thomas F. Geiler, Director
/ARNSCABLE,
r,MAn Aye$ Public Health Division
A FD + Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date:
Designer: Shay Environmental Services, Inc. Installer: SQO�i C
jAddress: P.O. Box 627 Address:
East Falmouth, MA 02536c�C � ; 1
On t)`5 ��ep was issued a permit to install a
(da e) (installer)
t
septic system at A based on a design drawn by
(ad es )
Shay Environmental Services, Inc. dated -
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes'(i.e.
greater than 10' lateral relocation of the SAS or any,vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
ZN OF 4q
CARMEN ��,
nstaller's Sign e) o E.
U SHAY N
No. '1181
GISTf
SANI TAR\
signer's Signature) (Affix De > tamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:HealtNSeptic/Designer Certification Form
*NOTE: ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C. SECTION A --A ALL OUTLET PEES FROM THE e✓ F `' 't (`�;$ivn+kt i
10' min. from OMW49UUM Box SMALL BE 1r CONCRETE COVER i PQAII`�'
Existing Foundation �house to septic tank - PROFILE VIEW OF ADDITION TO LEACHING SYSTEM SET uExi MR AT LEAST 2 FT-
Sptic lank mvsrs mud be D-BOX cover must be
TOP OF FOUNDATION = ELEV. 100.00 (Assumed) 9�e vrdhin 6 in. of finished grade 3 - S'OU1l1T
1
c within 6 in. of finished
Grade over Septic Tank - 99,00 Grade over D-Box- 99.00 over SAS - moo .3' of 1/8' - 1/2' Washed PeastKNOCK
//-- �- ade outs v
\1l 3/4' to 1 1/2 ' washed Gvahed Stye
OUTLET
emm
4� c V.
4'PVC(CAPPED)INSPECTION PORT TO BE
S 0.02 3 HOLE H-f 0 INSTAIIED AND TD BE MATH!! V OF GRADE - - _ , ,✓ 2 �,. 11 K!N 1 � .`r �'� ;r
T. BOX - 3' 1lmdmem Cover Top OF System- Ekw. -95.56 _ - 2' :{ r ♦ I
12. s=o.Q1 ar
EXIST. PIPE ^ 1,500 GAL 10' Greater Ss O.OI'per root ♦ O"Effective Depth 15.5' �`'ar'i% R-roe.+fie �° F �Q't !e t
4' - SCH. 40
Fifth EXIST. Ft LKMTIIIN w SEPTIC TANK CV
a Cb a-ewe. m 0 15, PLAN SECTION CROSS-SECTION (
CONCRETE rut Fa»tD�TTo►r-� o p H-10 N o, 0.83' 10 inches j; i £ z a ,� -� o
o >
O A C) 3' r"'' e In t t' i
HOLE H-10 DISTRIBUTION BOX oI
3 ..
SYSTEM PROFILE 6 in.of 3/4--1 1/Y z o 31.25` NOT To SCALE 10e '=v I � ^�` "
compacted stone e c 0) 37.25 n rennrdy�e+ ,
Not to Scale S c o A ♦ •s91 itrt�y62Afi KMP "tr�ry�
4' 4' I Effective Length> � r1g ,
0 3 T SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES
6 in.of 3/4'-1 1/2. 0 11' c
compacted stone < Effective Width INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN
NOTE ALL COMPONENTS,MUST HAVE RISERS TO YVITHIN 6' BELOW GRADE o 0 1. Contractor is responsible for Digsafe notification, Verification of Utilities
m (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes.
w Bottom of Test Hots f Dev-8a.00 NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10' 2. The septic tank and distri ution box shall be set
Groundwater Observed - NONE OBSERVED level on 6" of 3/4"-1 1/2" stone.
------ _"`- 3. Backfiil should be clean sand or gravel with no
stones over 3" in size.
4. This system is subject to inspection during installation
by Carmen E. Shay - Environmental Services, Inc.
P E R C 0 LAT I 0 N TEST 5. The contractor shall install this system in accordance
with Title V of the Massachusetts state code, the approved plan
Date of Percolation Test: JULY 18, 2005
and Local Regulations.
Test Performed By. CARMEN E. SHAY, R.S., C.S.E.
Results Witnessed By. WAIVER (Per Barnstable B.O.H.) 6. If, during installation the contractor encounters any
soil conditions or site conditions that are different
EXCAVATOR: Shay Env. Svcs. from those shown on the soil log or in our design
Percolation Rate: Less Than 2 MPI ® 30"
installation must haft do immediate notification be
-------------- ---- - made to Carmen E. Shay - Environmental Services, Inc.
Test Hole Test Hole LOT #1 7. No vehicle or heavy machinery shall drive over the
No. 1 No. 1 septic system unless noted as H-20 septic components.
DEPTH SOILS ELEV. DEPTH SOILS ELEV.', 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends-
1 D 99.00 D ---99.15 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
Sandy Loam Sandy Loom op - UD 10. All solid piping, tees & fittings shall be 4" diameter
TO YR 3/2 10 YR 3/2
Schedule 40 NSF PVC pipes with water tight joints.
0"-12' Ae 98.00 0'-9' Ae 8.4D' �y• �� 1 1. Municipal Water is Connected to ALL OF The Residence and Abutting
Sandy coney ,' LOT #2 Properties Within 150 Feet
Loom Loam
�� THE PROPERTY LINES ARE APPROXIMATE AND
w YR 5/6 /o 5/6 �`� COMPILED FROM THE SURVEY PLAN GENERATED BY
{12'- 28' 8• 96.40 9"- 30' 8• 96.65'
ROBERT McGLONE, P.E. OF YARMOUTH, MA
Medium Medium ENTITLED "RUDDER VILLAGE SECTION 11, HYANNISPORT, MA,
�'d sO"d PLAN BOOK 232, PAGE 125, DATED DATED MAY 20, 1968
�/ '� AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
zs r 7/4 ' 25 Y 7/4 SHEDS IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
28•- t32 C, 30"- 132 G THE SEPTIC SYSTEM INSTALLATION. -
' ` t PROJECT BENCH MARK
TOP OF FOUNDATION
TEST HOLE #2 EXISTING CESSPOOL TO BE PUMPED OUT REMOVED.
'00. = 100.00
- - ELEV.= 99.15 � ELEV. (Assumed)
99''� \ NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
• �D-Box
FROM THE EXISTING CESSPOOL TO BE DISPOSED
OF AS PER BOARD OF HEALTH SPECIFICATIONS.
Palled -"..� ?.�• \
_ . \ 0,
CESSPOOL ,�. \
I PROPERTY
THERE ARE NO WETLANDS ARE ES ENT WITHIN 200 OF THE PROPER
Perc 1 <:' �. • .�-` � t - __
Depth to Perc: 32" to 50" O i ASSESSORS MAP 247 PARCEL 166
Perc Rate= 2 MPI ` • -'`= 37. 5' r� I i
Groundwater Not Observed LEGEND
'
No Observed ESHWT �. • _--- 99, /
5
ADJUSTED H2O Elev. = None D �' p
DENOTES PROPOSED
CO; 104X i SPOT GRADE
TEST HOE #1 Cement EXISTING ' r
3-24' DIAM. ACCESS MANHOLES Patio 3 BEDROOM � �i DENOTES EXISTING
to' _6. ELEV.=-1 HOUSE
HOUSE y // rr X 104.46 SPOT GRADE
_�• ~�:; _ -� t`\ #r143o ; PL PROPERTY LINE
CO
\ PROPOSED CONTOUR
9�ET LOT 3 rt ' r��
\ # r
THE ACCESS COVERS FOR THE SEPTIC TANK, i - - - - - --97'
INLET r � Porch /' 13.603 Square Feet +/- r EXISTING CONTOUR
DISTRIBUTION BOX AND LEACHING COMPONENT
yT T• SHALL BE RAISED TO WITHIN 6" OF
• �:.-- ''� FINISHED GRADE.
DEEP TEST HOLE &
STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITE GAS BAFFLES OR EOUALS
PLAN VIEW ON ALL OUTLET TEE ENDS `�\ \\ \ _�\\_ ,9a PERCOLATION TEST LOCATION
3-2e REMOVABLE COVERS 6 FOOT STOCKADE FENCE
3 _min dearanc» ' 4 •' I S escr ----
AJIFT e' minT I r m1n. Inlet to outlet 6.
OUTLET -
5' -r _ L _ 7 S• -7' 9 \ ��5�• P�\, \ r , __'g P LOT P LAN
- : E g I 4'-0' min. /
�..... - ,> � LOT #4 0
b� f,- OF PROPOSED SEPTIC S'� STEM UPGRADE
---- \ - PREPARED FOR
�.
J 0 H N Y U S C AVA G E
CROSS SECTION END-SECTION 9 AT
TYPICAL CH- 10 LOADINGS 1500 GALLON SEPTIC TANK # KEEL LANE
NOT TO SCALE g �P�� HYANNISPORT, MA
Design Calculations ���• ��` Fiyq PREPARED BY:
Number of Bedrooms: 3 Equivalent to 330 Gat./Day (330 Gal./Day Min. per Title V) �� N c CARA li 1 ►' F- /.J ffA l
Garbage Grinder: No -
Leaching Capacity Proposed: 330 Gal:/Day Minimum (Min. Per Title V) / �F�
Septic -Tank - 2 x 330 Gal./Day= 660 USE NEW 1,500 GAL. Septic Tank. �' O � � ENVIRONMENTAL ,SERVICES, INC.
SOIL ABSORPTION AREA: Using percolation rate of C2 min./inch �' �� 1 o P.O. BOX 627
Bottom Area 0.74 gal/sq. ft._ x 370 sq. ft. _ 273.8 gallons 0 20 40 50 % of-ST0t` EAST FALMOUTH, MA 02536
Sidewali Area: 0.74 gal./sq. ft. x 78 sq. ft. = 58 gallons
Providing: = 331.80 gallons I; SANIrARtPa TEL./FAX : 508-539-7966
PW
Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1.=20' DRAWN BY: CES DATE: JULY 19, 2005
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF-WASHED STONE SCALE: 1"=20' ` PROJECT#SD773 FILENAME: SD773PP.DWG _`-SHEET 1 OF 1
ON THE ENDS. NO STONE UNDER:
I